Manejo de Disminución de Movimientos Fetales en pacientes del Área de Urgencias Obstétricas / Management of Decreased Fetal Movements in patients in the Obstetric Emergency Area

Los movimientos fetales son uno de los primeros signos de vitalidad fetal. Durante la gestación, éstos van apareciendo progresivamente. La adecuada adquisición y mantenimiento de los mismos durante la gestación indica un correcto desarrollo neuromuscular, así como de bienestar fetal1. La percepción materna de una Disminución de los Movimientos Fetales (DMF) constituye un motivo de consulta frecuente en los Servicios de Urgencias Obstétricas; toda paciente embarazada debe vigilar los movimientos fetales, mediante un conteo subjetivo de los movimientos del feto, a partir de las 24 semanas de gestación. La DMF constituye el 5 ­ 15% de motivos de consulta en los servicios de Urgencias en el tercer trimestre del embarazo. Hasta un 25% de fetos que presentan una DMF presentarán alguna complicación perinatal (malformaciones, retraso de crecimiento, parto prematuro, hemorragia fetomaterna, y éxitus fetal) incluso en población de bajo riesgo. El manejo inadecuado de la DMF representa un 10-15% de las muertes evitables a término1-3. Es por esto que ninguna paciente que consulte por Disminución de Movimientos Fetales debe ser dada de alta sin asegurarse del adecuado bienestar fetal.

Fetal movements are one of the first signs of fetal vitality. During gestation, they appear progressively. Adequate acquisition and maintenance of fetal movements during gestation indicates correct neuromuscular development, as well as fetal well-being1. Maternal perception of decreased fetal movements (DMP) is a frequent reason for consultation in Obstetric Emergency Departments; every pregnant patient should monitor fetal movements by subjectively counting fetal movements, starting at 24 weeks of gestation. FMD constitutes 5-15% of the reasons for consultation in the emergency department in the third trimester of pregnancy. Up to 25% of fetuses with FMD will present some perinatal complication (malformations, growth retardation, premature delivery, fetomaternal hemorrhage, and fetal death) even in low-risk populations. Inadequate management of FMD accounts for 10-15% of preventable deaths at term1-3. This is why no patient who consults for decreased fetal movements should be discharged without ensuring adequate fetal well-being.

Comparison between Protocols for Management of Fetal Growth Restriction / Comparação entre protocolos de acompanhamento da restrição de crescimento fetal

Abstract This comprehensive review compares clinical protocols of important entities regarding the management of fetal growth restriction (FGR), published since 2015. Five protocols were chosen for data extraction. There were no relevant differences regarding the diagnosis and classification of FGR between the protocols. In general, all protocols suggest that the assessment of fetal vitality must be performed in a multimodally, associating biophysical parameters (such as cardiotocography and fetal biophysical profile) with the Doppler velocimetry parameters of the umbilical artery, middle cerebral artery, and ductus venosus. All protocols reinforce that the more severe the fetal condition, the more frequent this assessment should be made. The timely gestational age and mode of delivery to terminate the pregnancy in these cases can vary much between the protocols. Therefore, this paper presents, in a didactic way, the particularities of different protocols for monitoring FGR, in order to help obstetricians to better manage the cases.

Resumo Esta revisão compreensiva compara protocolos clínicos de entidades importantes em relação ao manejo da restrição de crescimento fetal (RCF), publicados desde 2015. Cinco protocolos foram escolhidos para a extração de dados. Não houve diferenças relevantes quanto ao diagnóstico e classificação da RCF entre os protocolos. Em geral, todos os protocolos sugerem que a avaliação da vitalidade fetal deve ser realizada de forma multimodal, associando parâmetros biofísicos (como cardiotocografia e perfil biofísico fetal) aos parâmetros dopplervelocimétricos da artéria umbilical, artéria cerebral média e ducto venoso. Todos os protocolos reforçam que quanto mais grave a condição fetal, mais frequente essa avaliação deve ser feita. A idade gestacional oportuna e o modo de parto para interromper a gravidez nesses casos podem variar muito entre os protocolos. Portanto, este trabalho apresenta, de forma didática, as particularidades de diferentes protocolos de acompanhamento de RCF, a fim de auxiliar os obstetras no melhor manejo dos casos.

Atuação da psicologia em unidade neonatal no contexto da pandemia da covid-19 / The work of psychology in a neonatal unit in the covid-19 pandemic / Actuación de la psicología en una unidad neonatal en el contexto de la pandemia de la covid-19

A pandemia de covid-19 provocou intensas mudanças no contexto do cuidado neonatal, exigindo dos profissionais de saúde a reformulação de práticas e o desenvolvimento de novas estratégias para a manutenção da atenção integral e humanizada ao recém-nascido. O objetivo deste artigo é relatar a atuação da Psicologia nas Unidades Neonatais de um hospital público de Fortaleza (CE), Brasil, durante o período de distanciamento físico da pandemia de covid-19. Trata-se de estudo descritivo, do tipo relato de experiência, que ocorreu no período de março a agosto de 2020. No contexto pandêmico, o serviço de Psicologia desenvolveu novas condutas assistenciais para atender às demandas emergentes do momento, como: atendimento remoto; registro e envio on-line de imagens do recém-nascido a seus familiares; visitas virtuais; e reprodução de mensagens de áudio da família para o neonato. Apesar dos desafios encontrados, as ações contribuíram para a manutenção do cuidado centrado no recém-nascido e sua família, o que demonstra a potencialidade do fazer psicológico.(AU)

The COVID-19 pandemic brought intense changes to neonatal care and required health professionals to reformulate practices and develop new strategies to ensure comprehensive and humanized care for newborn. This study aims to report the experience of the Psychology Service in the Neonatal Units of a public hospital in Fortaleza, in the state of Ceará, Brazil, during the social distancing period of the COVID-19 pandemic. This descriptive experience report study was conducted from March to August 2020. During the pandemic, the Psychology Service developed new care practices to meet the emerging demands of that moment, such as remote care, recordings and online submission of newborns' pictures and video images for their family, virtual tours, and reproduction of family audio messages for the newborns. Despite the challenges, the actions contributed to the maintenance of a care that is centered on the newborns and their families, which shows the potential of psychological practices.(AU)

La pandemia de la COVID-19 ha traído cambios intensos en el contexto de la atención neonatal, que requieren de los profesionales de la salud una reformulación de sus prácticas y el desarrollo de nuevas estrategias para asegurar una atención integral y humanizada al recién nacido. El objetivo de este artículo es reportar la experiencia del Servicio de Psicología en las Unidades Neonatales de un hospital público de Fortaleza, en Ceará, Brasil, durante el periodo de distanciamiento físico en la pandemia de la COVID-19. Se trata de un estudio descriptivo, un reporte de experiencia, que se llevó a cabo de marzo a agosto de 2020. En el contexto pandémico, el servicio de Psicología desarrolló nuevas conductas asistenciales para atender a las demandas emergentes del momento, tales como: atención remota; grabación y envío em línea de imágenes del recién nacido; visitas virtuales; y reproducción de mensajes de audio de la familia para el recién nacido. A pesar de los desafíos encontrados, las acciones contribuyeron al mantenimiento de la atención centrada en el recién nacido y su familia, lo que demuestra el potencial de la práctica psicológica.(AU)

Analysis of antepartum cardiotocography based on S/k proportions and probability in 20 minutes / Análisis de la cardiotocografía anteparto mediante las relaciones S/k y la probabilidad en 20 minutos

Abstract Objectives: although mortality and perinatal asphyxia in newborns have been considerably reduced, there are still deficiencies in screening and diagnosis methods for intrapartum fetal well being that aim to detect its early alterations. Therefore, the purpose of this research was to apply a methodology based on probability and entropy and confirm its capacity to detect normal and abnormal fetal cardiac dynamics from 20-minute cardiotocographic tracings. Methods: 80 cardiotocographic tracings of pregnant women in the last trimester were collected, of which the minimum and maximum fetal heart rate were evaluated every 10 seconds, as well as its repetitions along with their probability and the diagnostic S/k ratio. Finally, the statistical analysis was carried out to establish the diagnostic capacity of the method concerning the clinical evaluation and interpretation of the cardiotocographic tracing, taken as the Gold Standard. Results: it was confirmed that S/k ratio values differentiated normal from abnormal fetal cardiac dynamics with sensitivity and specificity values of 100% and a Kappa coefficient of 1. Conclusion: the applicability of a diagnostic mathematical method of cardiotocography was confirmed, which suggests its implementation in the clinical context to detect alterations in fetal well-being in 20 minutes.

Resumo Objetivos: aunque se ha logrado reducir considerablemente la mortalidad y asfixia perinatal en neonatos, aún hay deficiencias en los métodos de tamizaje y diagnóstico del bienestar fetal intraparto que detecten sus alteraciones tempranas. Por lo anterior, el propósito de esta investigación fue aplicar una metodología basada en la probabilidad y la entropía y confirmar su capacidad para diagnosticar la dinámica cardíaca fetal normal de la anormal a partir de trazados cardiotocográficos de 20 minutos. Métodos: se recolectaron 80 trazados cardiotocográficos de gestantes en el último trimestre, de los cuales se evaluaron frecuencia cardíaca fetal mínima y máxima cada 10 segundos al igual que sus repeticiones, su probabilidad y la proporción S/k diagnóstica. Finalmente, se realizó un análisis estadístico para establecer la capacidad diagnóstica del método con respecto a la interpretación el trazado cardiotocográfico y la evaluación clínica, tomadas como Gold Standard. Resultados: se confirmó que los valores de la proporción S/k diferenciaron las dinámicas cardíacas fetales normales de las anormales con valores de sensibilidad y especificidad del 100% y un coeficiente Kappa de 1. Conclusión: se confirmó la aplicabilidad de un método matemático diagnóstico de la cardiotocografía, lo cual sugiere que su implementación en la clínica para detectar alteraciones del bienestar fetal en 20 minutos.

Is moderate intensity exercise during pregnancy safe for the fetus? An open clinical trial / Exercício de intensidade moderada durante a gravidez é seguro para o feto? Ensaio clínico aberto

Abstract Objective To determine the effect of treadmill walking on maternal heart rate (MHR) and cardiotocographic parameters (basal fetal heart rate [FHR], active fetal movements [AFM], number of accelerations and decelerations, and short-term variation [STV] and long-term variation [LTV] of fetal heart rate) in pregnant women at 36 weeks. Methods A nonrandomized, open clinical trial involving 88 healthy pregnant women submitted to moderate intensity walking and computed cardiotocography in 3 20- minute periods (resting, treadmill walking, and postexercise recovery). Results The mean FHR decreased during walking (resting: 137 bpm; treadmill: 98 bpm; recovery: 140 bpm; p<0.001), with bradycardia occurring in 56% of the fetuses in the first 10minutes of exercise, and in 47% after 20minutes. Bradycardia was not detected in the other phases. The mean STV and HV were 7.9, 17.0, and 8.0 milliseconds (p<0.001) and 7.6, 10.8 and 7.6 bpm (p=0.002) in the resting, walking and recovery phases, respectively. Themean number of fetalmovements in 1 hour was 29.9, 22.2 and 45.5, respectively, in the 3 periods (p<0.001). In overweight/obese women, the mean FHR was lower (p=0.02). Following the logistic regression analysis, two variables remained significantly associated with bradycardia: maternal fitness in the 28th week of pregnancy (protective effect) and maternal weight (increased risk). Conclusion In healthy fetuses, physical exercise proved to be safe, since, although FHR and AFM decreased during treadmill walking, an increase in SVT and LTV was observed.

Resumo Objetivo Determinar o efeito da caminhada em esteira sobre a frequência cardíaca materna (FCM) e parâmetros cardiotocográficos (batimentos cardiofetais basais [BCFs], movimentos ativos fetais [MAFs], número de acelerações e desacelerações e variabilidade de curta [STV] e longa [LTV] duração da frequência cardíaca fetal) em gestantes na 36a semana. Métodos Foi realizado umensaio clínico não randomizado e aberto com 88 gestantes saudáveis submetidas a caminhada de moderada intensidade na esteira e a cardiotocografia computadoriza em 3 momentos de 20 minutos (antes, durante e após a caminhada). Resultados A média dos BCFs diminuiu durante a caminhada, retornando a níveis prévios (antes: 137 bpm; durante: 98 bpm; após: 140 bpm; p<0,001), com bradicardia ocorrendo em 56% dos fetos nos primeiros 10 minutos do exercício, e em 47% após 20 minutos. A bradicardia fetal não foi observada em outrosmomentos (antes ou depois). As médias da STV e da LTV foram 7,9, 17,0 e 8,0milissegundos (p<0,001) e 7,6, 10,7 e 7,6 bpm (p=0,002) antes, durante e após a caminhada, respectivamente. Amédia dos números dos MAFs em 1 hora foi 29,9, 22,2 e 45,5, respectivamente, nos três momentos (p<0,001). Nas mulheres com sobrepeso/obesidade, a média da FCM foi menor (p=0,02). Após a análise de regressão logística, duas variáveis permaneceram significativamente associadas a bradicardia: aptidão maternal na 28a semana de gravidez (efeito protetor) e peso materno (aumento do risco). Conclusão Em fetos saudáveis, o exercício físico mostrou-se seguro, uma vez que, embora os BCFs e osMAFs diminuam durante a caminhada na esteira, foi observado um aumento da SVT e da LTV.

Obstetric practices performed by nurse-midwives of a hospital natural birth center / Prácticas obstétricas en centro de parto normal intrahospitalario realizadas por enfermeras obstetras / Práticas obstétricas em centro de parto normal intra-hospitalar realizadas por enfermeiras obstetras

Abstract Objectives: To characterize the practices used by nurse-midwives in a Natural Birth Center (NBC) and to verify the maternal and neonatal outcomes. Method: This was a cross-sectional, documentary, retrospective study with a quantitative approach in which the medical records of 300 parturients who gave birth in a state hospital in the city of São Paulo were analyzed. The categories of the World Health Organization (WHO) composed the criteria adopted for the analysis of the obstetric practices. Fisher's exact test or the likelihood ratio and Student t-test were used. Results: The nurse-midwives mostly used category A practices of the WHO. There were no statistically significant associations between practices and perineal outcomes. There was a statistically significant association between the weight of the newborn and the number of neonatal complications, as well as between the delivery position of the primiparous women and clavicle fractures of the newborns. Conclusion and Implications for the practice: Evidence-based practices were followed by the nurse-midwives in the NBC analyzed. The maternal and neonatal outcomes were adequate. There is a need to improve care in the second stage of the delivery in order to avoid behaviors that reflect in neonatal complications. The study makes it possible to reflect on the importance of the continuous evaluation of the care provided.

Resumen Objetivos: Caracterizar las prácticas utilizadas por las enfermeras obstetras en un Centro de Parto Normal (CPN) y verificar los resultados maternos y neonatales. Método: Estudio transversal, documental, retrospectivo, con abordaje cuantitativo, en el cual fueron analizados prontuarios de 300 parturientas que dieron a luz en hospital público de la ciudad de São Paulo. Los criterios adoptados para el análisis de las prácticas obstétricas fueron las categorías de la Organización Mundial de la Salud (OMS). Fueron utilizadas las pruebas, exacto de Fisher o razón de verosimilitud (Likelihood Ratio) y t-Student. Resultados: Las enfermeras obstetras utilizaron mayoritariamente las prácticas de la categoría A de la OMS. No hubo diferencia estadísticamente significativa en las asociaciones entre las prácticas y los resultados perineales. Se observó una diferencia estadísticamente significativa entre el peso del recién nacido y el número de intercurrencias neonatales, así como entre las posiciones de parto de las primíparas con la fractura de clavícula de los recién nacidos. Conclusión e Implicaciones para la práctica: Las prácticas basadas en evidencias son seguidas por las enfermeras obstetras en el CPN analizado. Los resultados maternos y neonatales se mostraron adecuados. Es necesario mejorar la asistencia en el segundo período del parto para evitar conductas que reflejen en las interacciones neonatales. El estudio posibilita la reflexión sobre la importancia de la evaluación continuada de la asistencia prestada.

Resumo Objetivos: Caracterizar as práticas utilizadas pelas enfermeiras obstetras em um Centro de Parto Normal (CPN) e verificar os desfechos maternos e neonatais. Método: Estudo transversal, documental, retrospectivo, com abordagem quantitativa. Analisaram-se prontuários de 300 parturientes que deram à luz em hospital estadual da cidade de São Paulo. Os critérios adotados para a análise das práticas obstétricas foram as categorias da Organização Mundial da Saúde (OMS). Utilizaram-se os testes exatos de Fisher ou razão de verossimilhança (Likelihood Ratio) e t-Student. Resultados: As enfermeiras obstetras utilizaram majoritariamente as práticas da categoria A da OMS. Não houve diferença estatisticamente significativa nas associações entre as práticas e os desfechos perineais. Houve diferença estatisticamente significativa entre o peso do recém-nascido e o número de intercorrências neonatais e entre as posições de parto das primíparas com a fratura de clavícula dos recém-nascidos. Conclusão e Implicações para a prática: As práticas baseadas em evidências são seguidas pelas enfermeiras obstetras no CPN analisado. Os desfechos maternos e neonatais mostraram-se adequados. Há necessidade de melhorar a assistência no segundo período do parto, evitando condutas que reflitam em intercorrências neonatais. O estudo possibilita a reflexão sobre a importância da avaliação continuada da assistência prestada.

Reviving external cephalic version: a review of its efficacy, safety, and technical aspects

Currently, the rate of cesarean sections being performed in Korea is approximately 40%, with Korea ranking 4th among the Organization for Economic Co-operation and Development countries with respect to cesarean deliveries. Breech presentation at term is an important indication for cesarean section among other factors, including medicolegal concerns and pregnancies in women of advanced maternal age. Term breech presentation is associated with a higher fetal mortality rate than that associated with a cephalic presentation. Therefore, in Korea, most of these women deliver by cesarean section to avoid the complications of vaginal breech delivery. However, cesarean section is itself associated with considerable obstetric morbidity and sometimes, mortality. External cephalic version (ECV) is a useful method to reduce the cesarean section rate in women with breech presentation and therefore to reduce the incidence of breech presentation at delivery. Studies have shown that routine use of ECV reduces the cesarean section rate by approximately two-thirds in term pregnancies with breech presentation. ECV is accepted as a safe, efficacious, and cost-effective method and is recommended by both the American College of Obstetricians and Gynecologists and the Royal College of Obstetricians and Gynecologists in all pregnancies with term breech presentation, if not contraindicated. In Korea, although most clinicians are aware of the option of ECV, their relative lack of experience in performing the procedure and fear of complications render them hesitant to perform ECV. This review is aimed at guiding obstetricians by describing the efficacy, safety concerns, and technical aspects of this procedure.

Fetal autonomic malfunction as a marker of fetal distress in growth-restricted fetuses: three case reports

Fetal growth restriction (FGR) is characterized by fetal compromise and delayed neurological maturation. We report 3 cases of early FGR in the 26th week of gestation, based on hemodynamic Doppler monitoring, conventional cardiotocography, and non-invasive fetal electrocardiography (NI-FECG). Fetal heart rate variability (HRV), beat-to-beat variations, and fetal autonomic brain age scores (fABASs) were normal despite the absence of umbilical diastolic flow in the first case and the pregnancy continued to 30 weeks. NI-FECG helped achieve better fetal maturity. Fetal HRV and fABASs were low in the second and third cases. Fetal demise occurred soon in both cases. We conclude that NI-FECG could be a prospective method for the detection of fetal distress in early FGR.

Effect of Structured Bed Exercise on Uterine Contractions, Fetal Heart Rate Patterns, and Maternal Psychophysical Symptoms of Hospitalized High-Risk Pregnant Women: A Randomized Control Trial

PURPOSE: This study examined the effect on uterine contraction frequency (UCF), blood pressure (BP), heart rate (HR), fetal heart rate (FHR) patterns and psychophysical symptoms (physical discomfort, anxiety, and depression) of structured bed exercise (SBE) in hospitalized high-risk pregnant women prescribed bed rest. METHODS: Forty-five hospitalized high risk pregnant women at >24 weeks of pregnancy prescribed bed rest were randomly assigned to the experimental or control group. From January to May 2014, data were collected using electronic fetal monitoring and patient monitoring of UCF, BP, HR and FHR patterns, and psychophysical symptoms were measured using the antenatal physical discomfort scale, state-trait anxiety scale, and Edinburgh postnatal depression scale. RESULTS: UCF, BP, HR, and FHR patterns (rate, variability, acceleration, and deceleration) did not differ significantly between the experimental and control groups. The experimental group showed a significant increase in baseline FHR after SBE within the normal range, and after SBE, it reduced to the FHR before SBE. The variability, acceleration and deceleration of FHR before and after SBE did not differ significantly between two groups. Moreover, there was no statistically significant difference before and after SBE in the experimental group. Also, the experimental group showed statistically significant decreases in physical discomfort score. However, there were no significant differences in depression and anxiety score between two groups. CONCLUSIONS: SBE in hospitalized high-risk pregnant women under bed rest did not increase the risk to the fetus, and relieved physical discomfort and anxiety. Therefore, SBE should be considered as a nursing intervention in hospitalized high-risk pregnant women.

Computerized Cardiotocography Analysis: Comparison among Several Parental Ethnic Origins / Análise de cardiotocografia computadorizada: comparação entre diversas origens étnicas

ABSTRACT Objective: We speculate that genetic racial disparity exists in fetal life and can be detected by modern computerized cardiotocography (cCTG) . Methods: This is a retrospective study comparing the results of the cCTG of pregnant patients at 37-42 weeks according to the parental ethnicity (black versus white). A cCTG was performed to analyze the variables of fetal heart rate (FHR). The cCTG variables analyzed were: percentage of signal loss; number of contractions; basal FHR; number of accelerations; number of decelerations; length of high variation episodes; short-term variability (STV); total trace duration time; and number of fetal active movements. Non-stress test (NST) parameters in the two groups were compared using the Mann-Whitney test for continuous data, and the Chi-square test for categorical variables. Results: We found a significantly lower number of active fetal movements (p 1/4 0.007) and longer periods of low variation (p 1/4 0.047) in the cCTG of black patients when compared with white patients. Conclusions: In conclusion, identifying the factors responsible for the variance in the objective analysis of CTG results is important to improve the outcomes of patients. Our study lends further evidence as to the importance of ethnicity in clinical cCTG interpretation.

RESUMO Objetivo: Especulamos que disparidade genética racial exist ana vida do feto, e que possa ser detectada por moderna cardiotocografia computadorizada (cCTG). Métodos: Estudo retrospective comparando resultados do cCTG de gestantes entre 37-42 semanas de gestação de acordo com etnicidade dos pais (negro vs. brancos). cCTG foi usado para analisar as variáveis a frequência cardíaca do feto (FHR). As variáveis abalizadas do cCTG foram o % de perda de sinal, número de contrações, basal FHR, número de acelerações, número de desacelerações, comprimento dos episódios de alta variação, viabilidade de curto prazo, tempo total de duração do rastreamento, e número de movimentos de atividade fetal. Os parâmetros do teste de não estresse (NST) em dois grupos foram comparados usando o teste de Mann-Whitney para dados contínuos e teste qui-square para variáveis categóricas. Resultados: Encontramos números significativamente mais baixos de movimentos de atividade fetal (p 1/4 0,007) e períodos mais longos de baixa variação (p 1/4 0,047) no cCTG de pacientes negros se comparados a pacientes brancos. Conclusões: Identificar fatores responsáveis pela variação na análise objetiva dos resultados de CTG é importante em resultados de pacientes que apresentam melhora. Nosso estudo fornece evidências adicionais à importância de estudos clínicos da etnicidade interpretada pelo cCTG.

Effect of Music Intervention on Maternal Anxiety and Fetal Heart Rate Pattern During Non-Stress Test

PURPOSE: The purpose of this cross-over experimental study was to examine effects of music intervention on maternal anxiety, fetal heart rate pattern and testing time during non-stress tests (NST) for antenatal fetal assessment. METHODS: Sixty pregnant women within 28 to 40 gestational weeks were randomly assigned to either the experimental group (n=30) or control group (n=30). Music intervention was provided to pregnant women in the experimental group during NST. Degree of maternal anxiety and fetal heart rate pattern were our primary outcomes. State-trait anxiety inventory, blood pressure, pulse rate, and changes in peripheral skin temperature were assessed to determine the degree of maternal anxiety. Baseline fetal heart rate, frequency of acceleration in fetal heart rate, fetal movement test and testing time for reactive NST were assessed to measure the fetal heart rate pattern. RESULTS: The experimental group showed significantly lower scores in state anxiety than the control group. There were no significant differences in systolic blood pressure and pulse rate between the two groups. Baseline fetal heart rate was significantly lower in the experimental group than in the control group. Frequency of acceleration in fetal heart rate was significantly increased in the experimental group compared to the control group. There were no significant differences in fetal movement and testing time for reactive NST between the two groups. CONCLUSION: Present results suggest that music intervention could be an effective nursing intervention for alel viating anxiety during non-stress test.

Fetal heart rate monitoring: from Doppler to computerized analysis

The monitoring of fetal heart rate (FHR) status is an important method to check well-being of the baby during labor. Since the electronic FHR monitoring was introduced 40 years ago, it has been expected to be an innovative screening test to detect fetuses who are becoming hypoxic and who may benefit from cesarean delivery or operative vaginal delivery. However, several randomized controlled trials have failed to prove that electronic FHR monitoring had any benefit of reducing the perinatal mortality and morbidity. Also it is now clear that the FHR monitoring had high intra- and interobserver disagreements and increased the rate of cesarean delivery. Despite such limitations, the FHR monitoring is still one of the most important obstetric procedures in clinical practice, and the cardiotocogram is the most-used equipment. To supplement cardiotocogram, new methods of computerized FHR analysis and electrocardiogram have been developed, and several clinical researches have been currently performed. Computerized equipment makes us to analyze beat-to-beat variability and short term heart rate patterns. Furthermore, researches about multiparameters of FHR variability will be ongoing.

Combined spinal-epidural anesthesia for urgent cesarean section in a parturient with a single ventricle: a case report / 대한마취과학회지

The number of women with major congenital heart defects reaching reproductive age is likely increasing. We herein describe the anesthetic management of a 33-year-old woman at 37 gestational weeks with a history of Glenn surgery who was undergoing an urgent cesarean section due to pathological cardiotocography. Combined spinal-epidural anesthesia was the most suitable technique for urgent cesarean section in our patient with a single ventricle and phasic flow in the pulmonary artery because it provided rapid-onset anesthesia with negligible hemodynamic effects.

Exercise stress test through brisk walking: A complimentary way to assess fetal well-being in term pregnancy / Philippine Journal of Obstetrics and Gynecology

OBJECTIVE: To determine the effect of exercise stress test (EST) through brisk walking on the cardiotocogram tracings (CTGs) and the association of the tracings to neonatal outcomes. METHODOLOGY: This one-group pretest-post test experimental study involved 65 term pregnant women (mean age = 25.94 + 4.66 years) who underwent brisk walking exercise using a motorized treadmill for 30 minutes, following American College of Obstetricians and Gynecologists (ACOG) guidelines for exercise among pregnant women. Pre- and post- walk CTGs were assessed, with presence of post-walk decelerations taken to mean a positive EST. Sensitivity (positive EST in sick / meconium-stained / cord coil babies), specificity (negative EST in well babies), positive predictive value (PPV) (probability of sick / meconium-stained / cord coil babies given positive EST) and negative predictive value (NPV) (probability of well babies given negative EST) were computed. RESULTS: A significant difference in the proportion of subjects with pre- and post- walk decelerations was noted (p-value = 0.000) wherein 18 subjects (28.13%) without decelerations in the baseline CTG had decelerations in the post-walk CTG. These decelerations were significantly associated to having sick, meconium-stained, or cord coil babies (p-values CONCLUSION: Exercise stress testing is a complementary way of assessing fetal well-being due to manifestation of decelerations in the post-walk CTG which could have gone undetected if only the resting CTG was done. The EST had high sensitivity for detecting sick / meconium-stained / cord coil babies and has the advantage of reinforcing a reassuring fetal condition due to its high NPV for detecting well babies.

Fetal Non-invasive Electrocardiography Contributes to Better Diagnostics of Fetal Distress: A Cross-sectional Study Among Patients with Pre-eclampsia

<p><b>INTRODUCTION</b>Fetal distress is a result of acute or chronic disturbances in the system of "mother-placenta-fetus" in pre-eclampsia (PE). The aim of the investigation was to compare the accuracy of antenatal fetal distress diagnostics in cases of traditional cardiotocography (CTG) waveform evaluation and analysis of morphological non-invasive electrocardiogram (ECG) parameters in anterpartum patients with PE.</p><p><b>MATERIALS AND METHODS</b>Fetal non-invasive ECG antenatal recordings of 122 pregnant patients at 34 to 40 weeks of gestation were examined. In Group I, there were 32 women with physiological gestation and normal fetal condition according to haemodynamic Doppler values. Group II involved 48 patients with mild and moderate PE whom were performed Doppler investigation. In Group III, 42 patients with severe PE were monitored with haemodynamic Doppler.</p><p><b>RESULTS</b>Fetal autonomic tone was lower with the relative increase of low frequency (LF) branch in the patients of pre-eclamptic group. The increased value of the amplitude of mode (AMo) and stress index (SI) was associated with adrenergic overactivity. It has induced pQ and QT shortening, increased T/QRS ratio and decelerations appearance. The rate of antenatal fetal distress retrospectively was 31.1 % in PE. The traditional analysis of CTG parameters has showed sensitivity (72.7%) and specificity (87.1%). In addition to the conventional CTG analysis, evaluation of ECG parameters has contributed to better diagnostics of fetal distress. Sensitivity and specificity of non-invasive fetal ECG were absolutely equal in this study (100%).</p><p><b>CONCLUSION</b>The results suggest that fetal non-invasive ECG monitoring is more objective than conventional CTG.</p>

Transient accelerations of fetal heart rate analyzed by computerized cardiotocography in the third trimester of pregnancy / Acelerações transitórias da frequência cardíaca fetal analisada pela cardiotocografia computadorizada no terceiro trimestre da gestação

Objective: the aim of this study was to investigate the patterns of transient FHR accelerations (10 bpm and 15 bpm) in the third trimester of pregnancy, comparing the occurrence of this event before and after the 32nd gestational week. Methods: This is a prospective study comparing the results of the computerized cardiotocography of 46 low-risk women with singleton pregnancies, maternal age between 18 and 40 years, gestational age between 28 and 40 weeks, absence of maternal morbidity and adequate fetal growth according to ultrasound. Computed Cardiotocography (8002 Sonicaid System and Fetal Care System) was performed for 30 minutes to analyze the variables of FHR. Results: twenty-three pregnant women underwent cardiotocography before 32 weeks (mean = 29.9 weeks, SD = 1.4 weeks) and were compared with 23 pregnant women who were examined after 32 weeks (mean = 36.3 weeks, SD = 2.5 weeks). Regarding the characteristics of FHR, fetuses evaluated between 32 1/7 weeks and 40 weeks showed a significantly greater number of accelerations above 15 bpm (median = 5, variation 0-18) than the group of pregnant women from 28 to 32 weeks (median = 4, variation 0 to 10; P = 0.048). There was a significant positive correlation between the number of accelerations above 15 bpm and the gestational age at examination (rho = 0.33; P = 0.026). Conclusion: computerized cardiotocography showed an association regarding the number of transient accelerations greater than 15 bpm in the assessment of both periods before and after 32 weeks of gestational age, suggesting the influence of the maturation of the fetal autonomic nervous system with pregnancy progression. .

Objetivo: o objetivo deste estudo foi investigar os padrões das acelerações transitórias da FCF (de 10 e 15 bpm) no terceiro trimestre da gestação, comparando a ocorrência desse evento antes e após a 32ª semana gestacional. Métodos: trata-se de estudo prospectivo comparando os resultados do exame de cardiotocografia computadorizada de 46 gestantes de baixo risco, com feto único, idade materna entre 18 e 40 anos, idade gestacional entre 28 e 40 semanas, ausência de morbidades maternas e crescimento fetal adequado pela ultrassonografia. Foi realizada a cardiotocografia computadorizada (Sonicaid System 8002 e Fetal Care System) por 30 minutos para análise das variáveis da FCF. Resultados: vinte e três gestantes que realizaram a cardiotocografia antes da 32ª semana (média = 29,9 semanas, DP = 1,4 semanas) foram comparadas com 23 que realizaram o exame após a 32ª semana (média = 36,3 semanas, DP = 2,5 semanas). Quanto às características da FCF, os fetos avaliados entre 32 1/7 semanas e 40 semanas apresentaram número significativamente maior de acelerações acima de 15 bpm (mediana = 5, variação 0 a 18) que o grupo de gestantes de 28 a 32 semanas (mediana = 4, variação 0 a 10; P = 0,048). Houve correlação significativa e positiva entre o número de acelerações transitórias acima de 15 bpm e a idade gestacional no momento do exame (rho = 0,33; P = 0,026). Conclusão: a cardiotocografia computadorizada revelou associação entre o número de acelerações transitórias acima de 15 bpm quando avaliados os períodos antes e após 32 semanas de idade gestacional, sugerindo influência da maturação do sistema nervoso autônomo fetal com a progressão da gestação. .

A prospective cohort study describing the neonatal outcomes of patients with different categories of intrapartal traces among pregnant women delivered at a tertiary hospital / Philippine Journal of Obstetrics and Gynecology

BACKGROUND: Continuous electronic fetal monitoring has been under close scrutiny due to lack of consistent interpretation of fetal heart rate tracings, even by perinatologists. In 2008, NICHD revised their definitions, interpretation and research guidelines. ACOG incorporated these guidelines into a 2009 practice bulletin on EFM definitions and the three-tiered fetal heart rate interpretation. After a year of adapting the new classification, the Department of Obstetrics and Gynecology of tertiary hospitals has yet to evaluate locally its use in fetal surveillance during labor and subsequently its value in decision-making. To date, no local study has been published regarding the neonatal outcome of those women whose intrapratal tracings were categorized under the three-tier system.OBJECTIVES: This study aimed to describe the neonatal outcomes of patients with Category I, II, and III traces among pregnant patients admitted in a tertiary hospital. This included APGAR score and disposition of the neonate as primary outcomes.METHODS: This was a prospective cohort study. It was conducted in a tertiary hospital from December 2012 to July 2013. The population consisted of women admitted in the labor room for delivery and underwent intrapartal monitoring and eventually delivered. Inclusions were term or preterm pregnancy ? 34 weeks, singleton pregnancy with no known congenital or lethal fetal anomalies. Exclusions were women with clinically evident chorioamnionitis on admission, multifetal gestations, preterm pregnancy (less than 34 weeks), post-term pregnancy, women who were mentally incapacitated to give consent, and those for outright cesarean section indications. There was no specified number of subjects but all laboring patients who underwent trial of labor in were included. Data was analyzed using descriptive analysis and z-test for proportion. And these data were held confidential. Reading and interpretation of the traces was made by perinatologist fellow on duty. Neonatal outcomes, on the one hand, including the APGAR score were analyzed by pediatrician on duty.RESULTS: There were a total of 163 subjects included in the study, with age range of 19-33 years old. Subjects were G1P0 to G9P6, with a mean prenatal check-up of 5 times. Among the 163 subjects, 134 had a Category I trace and 17 had Category II traces all through- out their laboring period, and the remainder had combination of category I and II traces. There was no Category III trace observed. For Category I trace, 97.8% of babies had a one minute APGAR score of 7-9, 1.5% had a one minute APGAR score of 4-6, and 0.7% had a one minute APGAR score of 1-3. The five-minute APGAR score with Category I trace were as follows: 99.3% had APGAR score of 7-9, 0.7% had APGAR score of 4-6, but there was none with a five-minute APGAR score of 1-3. Majority (63.4%) of the babies in Category I were direct room-in, 14.9 % were high-risk direct room-in, 10.4% babies were admitted in Neonatal Intensive Care Unit 2 (NICU2) and 11.2% in NICU3. Three (2.2%) of the babies in NICU3 were intubated. For the Category II trace, 100% of babies had one and five minute APGAR score of 7-9. Thirteen (54.2%) of the babies were direct-room in. 37.5% of the babies were admitted in NICU2. One baby (4.2%) was admitted in NICU3 but not intubated. The resuscitative measures done were as follows: tactile stimulation, thermoregulation, suctioning, inhalation, and intubation. Among these measures, suctioning (with a p-value of .02) showed a significant difference between Category I and Category II traces. Category II traces were associated more with abdominal delivery. Spinal anesthesia which was usually used in abdominal deliveries is also significantly different from the two traces, with a p-value of 0.02. Category I traces had a significantly higher morbidity and mortality compared to Category II traces.CONCLUSION: There was no significant difference between the one-minute and five-minute APGAR score and disposition of babies between Category I and Category II traces. Abdominal delivery, spinal anesthesia and suctioning were higher in Category II trace than in Category I trace.